Source: Healthcare Innovation
Key Highlights
- Organizations recommend increasing civil monetary penalties for hospitals non-compliant with price transparency rules to strengthen enforcement.
- Calls for hospitals to display negotiated rates in dollars and cents, and to publish quality information alongside pricing data.
- Advocates support extending site-neutral payments to more services and sites of care, starting with drug administration in 2026.
- Recommendations include using diverse data sources for physician payment rates and investing in primary care to improve healthcare value.
- Strong opposition was expressed to removing health equity adjustments, emphasizing their role in maintaining quality performance metrics.
Organizations Are Calling on CMS to Prioritize Consumer-Focused Medicare Payment Rules Reform
On September 16, the healthcare consumers advocacy group Families USA announced that, on behalf of Consumers First and 20 other organizations, it submitted a response to the Trump administration’s proposed rules for the Outpatient Prospective Payment System (OPPS) and Medicare Physician Fee Schedule (MPFS). The organization stated that these rules contain significant changes to hospital care and physician services Medicare payments.
Consumers First is a new alliance that unites the interests of consumers, children, employers, labor unions, and primary care providers, aiming to change the fundamental economic incentives and design of the healthcare system, as explained on Families USA’s website.
In the OPPS proposed rule comment letter, addressed to Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz, the organizations urged CMS to take additional steps to improve enforcement and compliance with the federal hospital price transparency rule.
Additionally, Consumers First recommended increasing the civil monetary penalty (CMP) for CMS noncompliance to $300 per bed per day for hospitals with 31 or more beds and removing the annual $2 million cap on the CMP for these hospitals. This, the organizations claimed, will send a stronger message.
Consumers First also encouraged CMS to require hospitals to display all negotiated rates in dollars and cents. “Only the negotiated rate, displayed in dollars and cents should be considered complete and accurate information for the purposes of the hospital price transparency rule.”
Furthermore, Consumers First recommended that CMS require hospitals to publish and pair quality information with pricing information. CMS should establish a process, the organizations advised, or build on existing processes, to engage a wide range of non-industry stakeholders to determine what kinds of quality information would be most appropriate and meaningful to pair with published prices.
Consumers First mentioned that it strongly supports CMS’s proposal to extend site-neutral payments to drug administration services delivered by “grandfathered” off-campus provider-based departments, starting in 2026. At the same time, Consumers First recommended that CMS go further and expand site-neutral payments to additional services and sites of care.
In the MPFS proposed rule comment letter, also addressed to Mehmet Oz, Consumers First expressed support for CMS’s proposal to cut the number of PE RVUs (Practice Expense Relative Value Units) for facility-based physician services. The organizations represented recommended that CMS take steps to ensure this proposed change does not negatively impact physicians who work in both the facility setting and a separate practice.
Furthermore, Consumers First recommended that CMS use a diverse set of data sources to determine physician payment rates, including hospital data (as used in OPPS), physician surveys, and routinely collected empirical data, to ensure that healthcare payments accurately reflect the value of primary care and the costs of providing a comprehensive version of it.
The letter writers recommended that CMS continue efforts to invest in primary care, streamline billing processes, and move away from the inefficiencies of traditional FFS (Fee For Service) by advancing more hybrid and population-based payment models.
Additionally, Consumers First expressed support for testing an alternative payment model at the individual physician level to assess cost and quality incentives that improve care for patients with heart failure and low back pain.
Consumers First strongly opposed proposals to remove the health equity adjustment, as retaining these quality measures is integral to ensuring quality performance, the organization explained.
